Introduction

Chapter 1. Introduction

In 2021, Médecins Sans Frontières (MSF) marked its fiftieth anniversary. The organisation that had begun with twelve people – all men, all French – around a table in December 1971 had grown to employ some 63,000 people across 162 nationalities (Cragg and Linna, 2022). That year, MSF ran programmes in more than 70 countries. In the top ten countries by expenditure, MSF’s combined spending was 570 million euros (MSF International, 2022a, p. 12). Across the world, it provided more than 12.5 million outpatient consultations, administered over 1.6 million measles vaccinations, performed some 112,000 surgeries, offered nearly 400,000 mental health consultations, and assisted 317,300 births (ibid, p. 13).

It is already obvious that an organisation operating at this scale cannot be just one thing. Indeed, inside MSF it is rarely even thought of as an organisation. MSF literature often refers to a ‘movement’ rather than an organisation, suggesting multiplicity and co-existence. One experienced MSF-er memorably described it as “30 boats with 30 captains,” each choosing to sail more or less together in the MSF fleet. Should any of those captains choose to take their boat in a different direction, the rest of the fleet has no recourse other than persuasion and consent. There is an internal lexicon to help describe the different kinds of boat in this fleet, from the ‘Operational Centres’ (OCs) that manage the movement’s medical humanitarian work, to the ‘partner sections’ that support the OCs, to the ‘associative’ structures that create space for MSF employees and former employees to be part of its governance at different levels. To study power within an organisation like MSF is therefore to study multiple things at once, and to leave many out.

Indeed, at the heart of our findings is recognition that power manifests differently in different places in MSF. As a result, what people describe as important depends on where they sit – both geographically and within existing political and social structures of inequality. Our study shows that inequality is inherent to MSF’s work, often justified by an appeal to emergency. This ‘emergency culture’ shapes many facets of MSF’s work – how decisions are made, how discussions are conducted, how the capacities and roles of different people are conceptualised, empowered, or constrained. Formal and informal powers are both crucial; abstract influences (such as values, imaginaries, and ideologies) have been codified and embedded in structures – such as contracts and policies – that bind some people more than others. Based on our research, many of these issues appear to feature across the MSF movement, although this varies and takes distinctive forms in Operational Centre Amsterdam (OCA, the focus of our study) and elsewhere. Throughout the research, we show how these dynamics manifest and we highlight some of their impacts, focusing on areas of particular relevance to OCA.

1.1 Studying power in MSF

This research was commissioned to analyse internal power dynamics while at duty and in day-to-day relations, between staff members and with patients. While it examines MSF, focusing particularly on Operational Centre Amsterdam, it has relevance for other humanitarian organisations. The objectives of the study were:

1. To document and assess how institutional and hierarchical power, both formal and informal, is distributed and functions within OCA both in the context of operational decision-making and in daily human relations.

2. To understand how inequalities, for example, those based on race, gender, nationality or professional domain (while recognising that identities are intersectional) are perpetuated by, and within, OCA.

3. To provide insight into how ‘coloniality’ may remain embedded in everyday humanitarian practices and discourses.

4. To provide an analytical resource for MSF to use when adapting human resources (HR) and operational structures so it can aim to be transparent about power and inequalities.

5. To inform MSF as it reflects on the legacies of its own action and presence in the many countries in which it operates.

The study contributes to understandings of power dynamics, inequalities and inequities within aid organisations and aims to provide a resource for those who seek to address the negative impacts of these. While unequal power dynamics within any organisation may raise questions of respect, justice, and dignity, in humanitarian organisations they are also closely tied to organisational values, identity, and purpose. Acknowledging prejudice and discrimination within a humanitarian organisation can lead to people questioning the integrity of their employer, of their colleagues, and of their own position. As a consequence of the commonly perceived overlap between what one does and who one is, addressing power inequities in MSF and the sector more generally can seem harder. Acknowledging power inequalities can be equally challenging, particularly in light of claims that aid agencies work ‘in service’ of communities facing crisis. Yet humanitarian organisations are no more exempt from power dynamics than they are exempt from politics – and indeed inequality is arguably a constitutive feature of the environments in which aid organisations work so it impacts their very ability to offer assistance.

In keeping with its objectives, the results of the study are analytical, not prescriptive. Nonetheless, they may – if explored and applied – have implications for the way that members and leaders of the MSF movement undertake their work or seek to influence the institution. By describing power and inequalities, this research may help to identify and prioritise potential target areas for reform. Importantly, although the research does not propose any specific approaches or solutions, it shines a light on the dynamics that reform efforts should take into account and which will shape perceptions and reactions to them.

This is far from the first study, within or beyond MSF, to consider power dynamics and inequalities within humanitarian organisations and in their practice. Exposure of power dynamics within the humanitarian sector has recently accelerated (The New Humanitarian, 2022). In 2020, the Black Lives Matter movement renewed the energy behind calls for reform. After decades of discussion around the need to ‘localise’ aid and shift power to actors and organisations in the Global South, humanitarians, activists and academics alike turned their attention to the explicitly racial nature of inequality and hierarchy in the aid sector. In particular, they highlighted the structural racism embedded in everyday aid practices, as well as in the hierarchy of trust, opportunity and pay that discriminates against locally hired staff (Ali and Murphy, 2020; Peace Direct, 2021; Hirsch, 2021a; Khan, 2021; Khan et al., 2021; Chaudhuri et al., 2021). As the critical literature on global health, aid and peacebuilding has shown, everyday interventions can end up reinforcing inequities among the very populations they are meant to help, as well as between humanitarians themselves (e.g. Kothari, 2006; Fassin, 2007; Benton, 2016; Pailey, 2020; Partis-Jennings, 2019; Hirsch, 2021a).

Within the aid sector, the MSF movement is a prominent player, comparatively heavily researched, and a producer of analysis and debate in its own right (e.g. Fox, 1995; Brauman, 2006; Redfield, 2006; Fassin, 2008; Rambaud, 2009; Abu Sa’Da, 2012; Desgrandchamps, 2011; Givoni, 2011; Magone, Neuman and Weissman, 2011; Redfield, 2013; Fox, 2014; Healy and Tiller, 2014; Abu Sa’Da and Crombé, 2015; Davey, 2015; Healy, Aneja, DuBois and Harvey, 2020). Internally, discussions about the treatment and representation of different staff groups are long-standing and detailed. MSF’s interventions have been shown to enact racialised inequalities among staff, which reflect and reproduce global structures of postcolonial inequity (Fassin, 2007; Shevchenko and Fox, 2008; Redfield, 2012; Souley Issoufou, 2018; James, 2020; James, 2022). Operational Centre Amsterdam, which today is the operational structure comprising MSF Holland and its partner sections (see box 1), has also been the subject of a series of studies on internal culture primarily at headquarters level (Heyse, 2006; Damman, Heyse and Mills, 2014; Rengers et al, 2019).

BOX 1: THE PATH TOWARDS TODAY’S OCA

Médecins Sans Frontières was founded in Paris in 1971, formed out of the shared interests of doctors and medical journalists to establish a medical humanitarian service, more agile than existing humanitarian organisations. For several years MSF remained small. In the early 1980s, however, the organisation grew rapidly in size and prominence and by the middle of that decade it was one of the most high-profile emergency aid organisations in France with growing international recognition. As more people gained experience of working for MSF, those who came from other parts of Europe founded new MSF sections in their home countries.

After the founding and consolidation of MSF in France, the second section to be established was MSF Belgium (1980), followed by MSF Switzerland (1981), MSF Holland (1984), MSF Luxembourg (1986) and MSF Spain (1986). A bitter dispute between MSF France and MSF Belgium in 1985 ultimately led to recognition that the existing organisation(s) held no power to stop new members from establishing or developing their own independent directions. Notwithstanding their common purpose and shared principles, as declared in the MSF Charter and elaborated in the Chantilly Principles of 1995, there were and remain differences in medical and political cultures in different parts of the movement.

The potential and actual expansion of the organisation in its early decades provoked contestation. In the early 2000s, there was a restructuring of the constellation of MSF entities. By this time, there were criticisms of what one former International Council President called “a worrying, but consistent pattern” that the “farther we go from the field in our organization, the more we grow” (Rostrup, 2002, p. 5; italics in original). Five of the oldest and largest sections became Operational Centres, mostly known by the city where their headquarters sat – MSF France became Operational Centre Paris (OCP), MSF Belgium became Operational Centre Brussels (OCB), and so on. Each of these had associated sections, however these were not distributed geographically. This structure allowed for variations in the way different OCs operate and how they relate to the rest of the movement.

Operational Centre Amsterdam was formed in 2006 from MSF Netherlands and its partner sections at the time – MSF Canada, MSF Germany, and MSF United Kingdom (UK) (Binet and Saulnier, 2019, p. 224-229). A 2009 guide for Heads of Mission in OCA described the centre’s desired management style as “a fine balance between demand-driven and desk-driven” (MSF OCA, 2009, p. 3). Today, the OCA Management Team comprises the General Directors (GDs) of MSF Netherlands, MSF Germany, MSF South Asia, and MSF UK, along with the MSF Netherlands Deputy Director, its Director of Operations and Advocacy, Medical Director, Staff Director, and Director of Resources. The General Director of MSF Netherlands serves as the Chair of the OCA MT. Partner sections are also represented on the OCA Council – the centre’s governing body – which includes representatives from the associative bodies of the constitutive sections (see MSF Netherlands, 2022, p. 75 13

The members of the research team for this study were all external to MSF, a departure from standard practice in an organisation that has significant internal research and evaluation capacity. At the same time, insider access and a broad remit gave this study the opportunity to explore dynamics which are not often formally captured or considered together. As one person remarked during a consultation for the study design, at MSF “we write a lot but there’s a lot we don’t write down.” One of the benefits of this research, therefore, is providing space for a range of views and experiences that may be excluded from, or siloed and isolated in, institutional documentation or independent studies.

Another benefit is the chance to have different formulations of systemic challenges that have already been recognised at different levels of the MSF movement. A different lens on these known challenges may help with the development of new approaches. As one participant said, speaking from their position in one of OCA’s country programmes, this is why “MSF needs to have you to do research on inequality and power dynamics in MSF. Because you lose it when you are in MSF every day, as much as you lose it when you live here every day.”

1.2 Challenging inequalities within MSF

This study has an ambiguous relationship with reform in MSF: on one hand, it was often perceived as part of such reform, because it provides analysis that may inform those seeking change. On the other hand, it treats reform in MSF as an area of academic investigation. It is beyond the scope of the research to give a full account of these reforms and the changes to the MSF movement over time; however, this history and current practice constitute an important context for the commissioning and conduct of this study.

The ‘La Mancha’ dialogue process and conference of 2006 are arguably the most important institutional touchstone for the reform of MSF. Held after a period of strong growth for the movement, they were designed to confront internal tensions over prioritisation and decision-making. During the discussions, the neglect and marginalisation of locally recruited staff (who made up 92% of MSF’s personnel) emerged as one of the central themes. It was at La Mancha that the prejudices and inequities hardwired into MSF’s principles and structures began to be recognised and challenged. This led to a broader discussion about the identity of the organisation; recognising that key decision makers and headquarters are in ‘the West’, attendees asked “are we French, European, international, global?” (Fox, 2014, p. 108). With the La Mancha Agreement (2006), MSF sections committed to “provide fair employment opportunities for all staff based on competence and commitment” (Article 2.12) and to “take proactive steps to ensure fair opportunities for access to meaningful membership in associations, while preserving the spirit of volunteerism” (Article 2.13).

In the years since La Mancha, these issues have ebbed and flowed in their prominence and in the level of institutional investment in addressing them. Although it is clear there have been changes, perceptions of them vary and this study did not seek to assess the extent of progress against the La Mancha commitments or any other benchmark. In our interviews, notably with OCA staff but also others, there was widespread agreement that meaningful attention dates only from 10 years ago at most. One interviewee with a long involvement with OCA reflected:

“There was inequality from the beginning, but it was not recognised as an issue and it is only in recent years that it has become an issue. I think under the influence of Me Too and Black Lives Matter movements, in general the world is taking a different view these days. And that is very recent in my perception, [this is a] different view as to how we should position ourselves towards one another and how we relate and divide power between different entities, power holders, in this world. All this […] has become an issue in the last… I think if I say 5 to 10 years then that might already be a wider timeframe than it actually is.”

Within this timeframe, there have been a range of initiatives – from institutional commitments at the international level, to projects spearheaded by or within specific OCs or sections, grassroots campaigns by employees taking action in their own workplace, and insurgent pressure groups aiming to leverage external attention.

These initiatives included:

• The 2017 ‘People, People, People’ statement from the Executive Committee (ExCom), the highest executive body of the MSF movement, which affirmed that the Full ExCom “commits, as a group and individually, to exercising the leadership required to bring about this change, restoring the trust between the organisation and the individuals that are an integral part of it. It will be pro-active, face the hard questions and take action” (MSF Full ExCom, 2017, p. 2).
• The 2018 ‘Call for Change’ issued by the International Board outlined four key areas requiring concerted effort: medical relevance and quality of care; value and support given to people in MSF; the effectiveness of the organisation’s public voice; and the cultural and organisational shifts required to achieve change (MSF International Board, 2018).
• The 2020 Core ExCom ‘Message to Our Staff on Discrimination and Racism within MSF’, which stated that “despite years of raising awareness and efforts at implementing new policies – we acknowledge that progress is nowhere near fast enough” and “we know that these changes need to go much further to provide a more just and equitable environment to our staff” (MSF Core ExCom, 2020).
• The 2022 update on ‘Tackling Institutional Discrimination and Racism within MSF’, from MSF International, which captures joint work arising from the Core ExCom’s 2020 message (MSF, 2022). The related action plan features seven priority areas: management of abuse and inappropriate behaviour; staff reward, including remuneration and benefits; exposure to risk – safety and security; people recruitment and development; communications and fundraising; standards of care for the patients and communities with whom MSF works; and executive governance and representation.

There are also several internal networks and projects addressing discrimination, inequities, and inclusion within OCA specifically and MSF in general.

Unofficial initiatives have also presented opportunities for different voices to speak on these issues and in some instances have driven responses from leadership. Most notably, in the wake of the Black Lives Movement, a ‘Decolonise MSF’ group formed, which aims to “abolish all kinds of discrimination at MSF, and to empower labour in service to this goal.”1 In 2020, an open letter that denounced MSF as institutionally racist and reinforcing white supremacy in its work was signed by over 1,100 current and former members of staff, including some at the time or recently in positions of leadership. In 2021, two Decolonise MSF organisers published Dignity at MSF, a movement-wide report on abuse and discrimination based on findings of an online survey with 359 current and former staff and stakeholders (Mukerjee and Majumdar, 2021; see also Majumdar and Mukerjee, 2022).

These different efforts and conversations have highlighted questions of exclusion and discrimination within MSF. The approaches to these issues – the terminology, the concepts, the thresholds of action – have changed over time and vary in different parts of the movement. By examining power, this study aims to enable reflection on the fates and prospects of these discussions and actions, the terms on which they are undertaken, and the dynamics that shape how they play out.

1.3 About this research

This research offers a partial view of a very complex and multifaceted issue. The study has its origins in internal conversations but was designed and conducted by external researchers. Inevitably, it is shaped by its own subject matter, as the processes of defining the scope of the research and how to go about it were themselves affected by power dynamics. More information about the origins of the study, the approach we took to the research, and some of its limitations, is discussed in Chapter 2.

At this point, we want to draw attention to some things all our readers should be aware of. First, this research gives significant space to the views that we have heard from participants in the study and its analysis is a result of these many voices. While there are patterns, the views are not always reconcilable and the extent to which they align with official institutional positions varies; although the research highlights potential implications of these portrayals, experiences and opinions, it is not an audit or a work of investigative journalism. Where relevant and possible, we have also used documents that often capture specific moments or attitudes.

In reading this research it is important to pay attention to the language used by interviewees to describe power hierarchies and inequalities in MSF. Depending on people’s positionalities and lived experiences, their political affiliations and activism, narratives range from mentions of ‘discrimination’ or ‘structural inequality’ to ‘racism’ or ‘white supremacy’. Different people use different vocabularies to speak about witnessed injustices, their roots and personal and professional consequences. In our analysis we have followed the lead of the people we spoke to. This means that, depending on the positionality of the reader, our analysis may at times seem either too muted or too forceful. We did this not to align ourselves with a particular politics, but rather to remove our own views and lenses as much as possible and to foreground the views of study participants. As such, the political language of the research is a reflection of the myriad views and dominant cultures in MSF.

Second, despite our attempts to create space for the range of perspectives, we have worked within significant constraints. As we discuss in Chapter 2, our sample inevitably reflects diverse and particular perspectives. We have interviewed many different people with different roles and relationships with MSF. Given the number of participants, many are not directly represented. However, all the interviews helped this project and we want to reiterate our gratitude to everyone who took part.

Third, it is important to make clear that the majority of people who contributed to this study described feelings of belonging and loyalty to MSF even as they articulated criticisms that sometimes cut to the heart of the institution. While this tension was often visible, the subjects of critique and the motivations for continued engagement vary from person to person.

Finally, we have chosen not to name anyone. When given the choice of how their interview could potentially be used, participants had three main options:

1. For quotes to have their name attached.
2. For quotes to be de-identified (removing not only their name but any information that would link the comment to the person).
3. To inform the study as background only.

A significant proportion were comfortable with their names being associated with their comments. A larger group opted for de-identified contributions, meaning that their views could be directly represented but suggesting that they were not comfortable being associated with those positions. A smaller group preferred to inform the study only on background, and an even smaller number were not comfortable with being recorded – even for notetaking. The politics of who feels safe to speak are complex, unpacked in different parts of the research, and they have influenced our choice to de-identify all participants in the study.

1.4 Roadmap

Chapter 2 discusses our scope and methodological approach in further detail.

Chapter 3 sets the scene by introducing the notion of emergency culture, which runs as a thread throughout the power dynamics in the research. MSF’s work is shaped by the idea of an emergency: a sudden, unpredictable break from normality that requires urgent and immediate action. While not all of MSF’s work can be characterised in this way, it is an imaginary with important material consequences: the framing of a situation directs some actions while precluding others.

Chapter 4 introduces key axes of inequality within the movement: the most frequently referenced inequalities within MSF, that both reflect and reproduce broader structures of inequality. It then describes six ‘currencies of influence’ frequently raised during interviews with MSF employees: time in ‘the field’; friends in high places; whiteness; English language skills; masculinity; and medical expertise.

Chapter 5 explores who is understood to ‘be MSF’, arguing that the way MSF identity has been historically constructed draws on certain tropes about who is neutral, and who embodies expertise and competency. It shows how this reinforces power hierarchies in countries of operation and in the movement’s associative structure.

Chapter 6 examines the power concentrated in coordination positions. It argues that, as intermediaries between headquarters and the majority of (locally recruited) staff, coordination posts filter information, opportunities, and particular policies into practice. This form of power is strictly hierarchical but also highly individualised, with direct consequences for career progression, opportunities for participation, and the handling of the safety, security, and health of different staff.

Chapter 7 considers the politics of legitimacy at headquarters level. It focuses on the spirit of volunteerism and proximity to ‘the field’, outlining their impacts on opportunities to enter the organisation and internal dynamics. In so doing, it highlights one of the ways informal power is used: to define what subjects or activities represent legitimate uses of resources. The chapter focuses on time because this is a key resource within the emergency culture of MSF.

Chapter 8 lays out some of the main narratives that staff used to describe perceived blockages to the reform of MSF or the evolution towards greater equity and inclusion. Recognising that these discourses can shape the space and motivation for action, it does not seek to test the validity of these claims but to document their presence and the way they reflect and produce disconnects across the movement.

Chapter 9 concludes with reflections on efforts to make meaningful change, different ideas about how that could or should happen, and the combination of faith and dismay that appears to shape how employees in OCA and MSF relate to the institution.

Ultimately, emergency shapes what reform initiatives are deemed possible. The organisation’s structures, and the inherent inequalities they reproduce, are justified by the moral appeal to saving lives in an emergency. Formal and informal inequalities are interconnected and interact in complex ways, they cannot be addressed separately. As some interviewees concluded, more radical change might need to be epistemic as well as structural: not only diversifying who carries out MSF’s work, but also giving people the power to shape and conceptualise what MSF is fundamentally about.